CONSENT FOR PROACTIVE HEALTH COACHING

 

Coaching is intended to simplify, motivate, and prompt behavior change.

Coaching is not a substitute for medical treatment by a licensed healthcare provider.

Information offered is not meant to be construed as medical advice or to be diagnostic or therapeutic.

 

It is critical that you read and understand this document thoroughly.

 

 

 

I,__________________________________________, hereby agree to the following: 

 

  1. I certify that I have not been advised by a qualified medical professional to avoid or limit certain lifestyle changes. In addition, I am unaware of any health-related reasons for which would preclude my participation in strenuous physical exercise. I assume the risks involved in my lifestyle changes that may test my physical and mental limits & may carry with it the potential for death or serious injury.  Risks may include but are not limited to, adverse consequences caused by the environment, equipment, actions of other people and lack of hydration or nutrition.

  2. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. These changes include abnormal blood pressure; fainting; disorders in heartbeat; heart attack; and, in rare instances, death.

  3. I recognize that an examination by a physician should be obtained prior to involvement in any exercise program. If I have chosen not to obtain a physician’s permission prior to beginning exercising or other form of lifestyle change, I hereby agree that I am doing so at my own risk, understanding the potential for adverse consequences.

  4. In a medical emergency, I will call 911.

  5. For medical advice, I will contact an appropriate healthcare provider.

  6. Improving one’s health is NOT an exact science, and I acknowledge that no guarantees have been made as to the results of services.

  7. I have been advised by Proactive Health Solutions to consult the appropriate healthcare provider before taking on any life changes. I will discuss all recommendations and services rendered with the appropriately licensed healthcare provider. If I believe that is not necessary, then I will carefully evaluate and take responsibility for all the medical risks of participation in any suggestions or instructions discussed. 

  8. I assume full responsibility for the actions I take to improve my health.

  9. I understand at no point will there be a Doctor client relationship between Proactive Health Solutions, LLC, Darren Swartz M.D. or myself.   

  10. I am aware that Darren Swartz, M.D. and certified ACE Health Coach is NOT a licensed or practicing M.D., D.O., chiropractor, nurse, dietitian, physical therapist or any other type of licensed practitioner. I know I can freely seek or continue such services at any time from a licensed practitioner.  

  11. Health coaching does NOT include: performing physical exams, blood draws, or medical procedures. Also, a coach does NOT provide medical diagnoses, prescribe medical treatments, nor recommend discontinuance of these treatments. Therefore, information should not be construed directly or indirectly as dispensing medical advice for the cure or mitigation of any disease or condition.

  12. I will allow Proactive Health Solutions, and its employees to use email/Zoom/Wix Chat/etc. to send me health information that may include personal health information.

  13. I will take full responsibility for my records, which includes both physical and electronic copies.

  14. I understand that Proactive Health Solutions will not keep a copy of my records with the exception of this consent.  

  15. I understand that Uptodate, or another resource, may be used to help me understand my health so that I can better communicate with my physician.

  16. I fully understand a health coach’s scope of service:      

    • Apply effective communication skills, such as the use of open-ended questions, affirmations, reflective listening, and summarizing to help a client or patient increase motivation and ownership of making a change           

    • Help clients and patients develop achievable and measurable goals to monitor success and motivate ongoing behavior change

    • Help clients and patients develop and exploit strengths to support successful behavior change

  17. I understand the following actions, among others, are outside defined scope of practice for health coaches:

    • Counseling or therapy

    • Nutrition prescription and meal planning

    • Exercise prescription

    • Diagnosis of medical or mental health ailments

    • Recommendation or sale of supplementation

18. I have completed the PAR-Questionnaire.

Your personal information will not be shared with your employer.

I have had the opportunity to ask questions and freely agree to the terms as expressed.

Your Signature